Gastrointestinal RadNotes

Contents:

  • Esophagus

  • Stomach

  • Duodenum

  • Small Bowel

  • Colon

  • Nondiaphragmatic Hernias

  • Pneumatosis Intestinalis

  • Mesenteric and Omental Masses

  • Acute GI Disorders in Children and Infants

  • Liver

  • Spleen

  • Pancreas

  • Miscellaneous GI Diseases

  • Barium Solutions

  • Ultrasound of the GI Tract

  •  

    Esophagus

    ESOPHAGEAL MOTILITY
    peristaltic waves mediated by vagal nuc in medulla
    myenteric plexus of auerbach propagates p stim by vagus
    tertiary or segmental contractions, nonpropulsive, N?
    >200mmHg abn press

    ABN STRIATED MUSCLE & UPPER ESOPH SPHINCTER
    GERD is the most common cause of dismotility

    1. Cricopharyngeal Achalasia - no relaxation of esoph sphinc
    sm impression can be asym, seen at C5-6 level
    more severe results in spillage into larnyx
    see enlarged piriform sinuses, barium retains in vallecula
    cricopharyngeal myotomy can reduce Sx

    Zenker's Diverticulum - mucosa thru Killian's dehiscence
    below inf pharyngeal constrictors & over Cricopharyngeus
    Tx w cricopharyngomyotomy or diverticulectomy

    2. Total Laryngectomy - Pseudodefect
    s/p laryngectomy, all landmarks absent
    appears similar to post cricopharyngeal impression
    shape changes w swallowing
    recurrent tumor will be a fixed defect

    3. S/P Radiation Therapy - causes paresis and dec sensation
    also hypopharyngeal retention, all result in aspiration

    4. Primary Muscle Disorders - failure to initiate peristalsis
    Myasthenia Gravis - no trasmission from motor end-plate
    initial swallow N, then fatigues quickly
    resolves w neostigmine
    Myotonic dystrophy - auto dom, muscle can't relax p cont
    poor cricopharyngeus resting tone, high aspiration
    Polymyositis & Dermatomyositis - inflam deg Dz of st musc
    weak and discoordinate musc, dysphagia, regurg & asp
    AML - loss of motor neuron fxn

    5. Primary Neural Disorders - cause motor discoordination
    peripheral or central cranial nerve
    Vagotomy - high unilat p tumor resec, discoord upper
    MS, Huntingtons, Diphtheria, Tetanus
    ABN SMOOTH MUSC & INNERVATION OF LOWER ESOPH

    1. Scleroderma - atony II' to atrophy of sm musc in 80% of pt
    may be asym, upper 1/3 continues to work
    patulous lower, reflux and stricture in 40%
    NO response to methylcholine test (R/O Achalasia)
    other con tissue diseases also cause this
    SLE, RA, Poly & Dermatomyositis
    all assoc w Reynaud's, a vasospastic neurogenic abn

    2. Myenteric Plexus Destruction - simulates achalasia
    II' to inflam like chaga's dz, or metastatic malig invasion

    3. Esophagitis - corrosive agents, reflux, infec, radiation
    failed I' peristalsis to stomach, III' waves beyond
    complete aperistalsis if severe

    4. Alchoholic & Diabetic Neuropathies
    selective deterioration of esoph motility, esp distal
    diabetics have diffuse dec amplitude of contraction

    5. Presbyesophagus - inability to initiate or sustain I' peri
    Anti-cholinergic agents - Atropine & probanthine
    simulate scleroderma w aperistalsis & dilation
    Myxedema and amyloid similar

    FAILED RELAXATION OF LES
    1. Achalasia - obs of dist esoph w prox dilation, 20-40 y/o
    Failed sphincter relaxation, barium retained >2.5 sec
    No gang cells in auerbachs plexus, no cholinergic cont
    mecholyl causes a denervation hypersensitivity resp
    hypercontraction & vomiting results
    Interupted peristaltic reflex arc, no lower sphinc relax
    high vagus interuption, or auerbachs disruption
    may see vigorus tertiary cont, hyperactive achalasia
    Regurg & aspiration can occur, chronic scarring etc
    CXR shows dil w retained food, can compress trachea
    sm or absent gastric air bubble
    Barium exam must be done in recumbent position
    DDx between malig & benign
    Benign - <40 y/o, sx <6 mo, N mucosa, smooth taper
    Malig - irreg in barium stream, thick st at fundus
    5-10% develop sq cell due to irritation
    Amyl Nitrate cannot relax sphincter
    Sedlitz test - carbonation in esoph cannot open
    Tx - balloon dil, perf may not be evident immediatly

    2. Chagas' Disease - dest of myenteric plexus by neurotoxin
    Typanosoma Cruzi - protazoan from armadillo
    assoc w megacolon as well

    3. Neuropathy
    central or peripheral can result in achalasia
    Bilat vagaotomy - sx in 7-14 days, clears in 2 mo
    Diabetes and congenital or acquired innervation degen

    4. Malignant Lesions - mets to midbrain or vagus nerves
    I' or met lesions of dist esoph or gastric cardia
    removal often results in restoration of fxn

    5. Esophagitis - post reflux stricture
    assoc w hiatal hernia


    TERTIARY CONTRACTIONS
    can be superimposed on N esophageal motility w/o sequela

    1. Presbyesophagus - #1, interupted reflex arc II' to age
    usually asym, if assoc w dec lower relax dil can occur

    2. Diffuse Esophageal Spasm - classic triad, rarely all 3
    bad discoord cont, chest pain & inc intralum pressure
    peristalsis N initially, but breaks up at arch level
    "Corkscrew", or rosary bead app to esoph, pseudodiverticuli
    "Nutcracker Esophagus" - Norm peristaltic wave seen, not distortion
    NO abn seen on esophagram, manomatry shows P >200mmHg
    Tx - procardia & nitro questionable, longitudinal myotomy curative

    3. Esophagitis - continues exitation of sensory receptors
    reflux, candida, amyloidosis, postirradiation

    4. Nutcracker esophagus - a manometric Dx
    N I' peristalsis, high amplitude dist cont

    5. Neuromuscular - DM, AML, MS, myxedema, myotonic dys, etc

    EXTRINSIC IMPRESSIONS ON THE CERVICAL ESOPH
    1. Cricopharyngeus Muscle - post C5-6, sim total laryngectomy

    2. Pharyngeal Venous Plexus - ant at C6, lax mucosal folds
    may vary from swallow to swallow, N in up to 90%

    3. Esophageal Web - usually ant & thin, may be mult & rounded
    never post

    4. Anterior Marginal Osteophyte - smooth reg post indentions
    usually asym, may cause dysphagia or irritation

    5. Thyroid Enlargement - usually displaces trachea as well
    watch for parathyroid enlargment as well, esp w Ca+ sx

    6. Ectopic Gastric Mucosa - seen in 4%, congenital & asym
    columnar epi in upper esoph, squa epi distal

    7. Malignancy - extrinsic mass or lymph node enlargement


    EXTRINSIC IMPRESSIONS ON THE THORACIC ESOPH
    note whether pushed or pulled by shape of lumen

    1. Normal Structures - aorta, L bronchus, L inf pulm vein

    2. Vascular Abnormalities
    Right side aortic arch - #1, no L aortic knob on CXR
    impression caused by R subclav passing post obl
    subclav can have 2 other routes w no impression
    Cervical aortic arch - supraclavicular, post to esoph
    Double aortic arch - S shape indention, or ring arch
    Coarctation of the aorta - fig 3 sign on CXR
    sx in late childhood, notched ribs due to collat flow
    Aortic anuerysm - sickle like displacement of esoph ant
    Aberrant R subclavian - arise dist to L subclav, post
    Abberant L Pulm art - arise from R pulm, Ant to esoph
    Anomalous pulm venous return - type III passes to diaph
    indents ant & inf to L atrium indention
    Persistent Truncus art - dil bronchial vessels, post

    3. Cardiac Enlargement
    Left Atrium - ant impression, may shift esoph to R
    L ventricle - inf to enlarged L atrium
    pericardial tumors, eff or cysts

    4. Intrathoracic Masses - mediast, lung, trachea etc

    5. Thoracic Osteophytes - more common in cerv, assoc w DISH

    6. Paraesophageal Hernia - usually displaces post and R

    7. Appical Plueropulmonary Fibrosis - retract toward lesion
    assoc w inflam dz like TB etc

    ESOPHAGEAL ULCERATION
    1. Reflux Esophagitis - #1, acid & pepsin or alk bile & panc
    failed LES, 26% of hiatal hernias, prolonged NG
    Chalasia - LES fails to remain closed, common in infants
    late preg hormones cause generalized SM relaxation
    S/P Heller procedure for achalasia - severed obl musc
    Tc99 DTPA given orally can be used for reflux study
    Baruim is insensitive to early esophagitis - use scope
    double contrast can detect ulcers, fine lines & dots
    single contrast see granular & serrated mucosa
    mult fine trans folds are early sign - feline esoph
    longitudinal folds thicker than 3mm
    lg trans folds - scarring
    Centinal Fold - lg long stom fold extending into esoph
    Penetrating ulcers - can form in up to 15%, perf prob

    2. Barrett's Esophagus - most in white males, inc w age
    Z line jxn to squa epi moved caudally by columnar epithelium
    represents B ring, Schatski's ring if <13mm
    Hiatal Hernias assoc but not always
    UGI - reticular mucosal pattern similar to "aeria gastrica" type pattern
    Ulcer formation freq, gastric like w freq stricture
    may be tapered only, retic pattern at edges suggestive
    Inc Ulceration & stricture = inc odds of Barret's
    Pertechnatate - taken up in gastric mucosa, diagnostic
    Usually never returns to normal even after Tx

    Adenocarcinoma - 10%, like squa cell but spreads dist
    30% of esoph Ca, all arise II' to Barretts
    Polypoid & ulcerative, assoc w stenosis, stage sim to SCC

    3. Candida Esophagitis - most compromised, 75% of aides pts
    Abx esp Tetracylcine can allow overgrowth
    Thrush - oral involvement only
    Adenophaygia - pain w swallowing, intense & local, MI
    Pseudomembranous plaques - upper 1/2 may be spared
    nodular cobblestone pattern w lg discrete ulcers
    shaggy marginal contour due to sloughed mucosa
    AIDS - may present w single lg ulcer, resembles ca
    Amphotericin B - Tx
    4. Herpetic Esophagitis - can be identical to candida
    discrete ulcers w less shaggy mucosa, self limiting

    5. Cytomegalovirus Esophagitis - dist ulceration, fundus poss

    6. TB Esophagitis - II' to terminal Dz in the lungs
    fistulas common, miliary nodules, midesophageal

    7. Crohn's Esophagitis - go to "ulcerative lesions of the colon"
    Aphthous ulcers - earliest sign, punctate, slit or ring
    radiolucent halo, linear or serpiginous later
    fistulas & perforation, diffuse cobblestone rare
    rarest site in GI tract

    8. Eosinophilic Esophagitis - fine superficial ulcerations
    Dr Hinder assoc w dysphagia in young men

    9. Carcinoma of the Esophagus - 95% squamous
    Meniscoid ulceration - bulging mass around a crater
    Met nodes may ulcerate into esoph

    10. Corrosive Esophagitis - inflam changes, mostly dist 2/3
    Alkali #1, penetrates deep layers, liquefying nec
    Acid less severe, coags outer layers, protective
    Scarring & narrowing

    11. Radiation Injury - >4500 rads, diffuse inflam, stricture
    2000 rads in combo w adriamycin or actinomycin D
    resembles candida which is much more common

    12. Pill Ulcers - tetracycline, KCL, Fe+, vit C, etc
    transition between sm & striated musc @ aorta #1

    14. Intramural Esophageal Pseudodiverticulosis - sim ulcers
    dilated esophageal glands - Innumerable outpuchings
    appear as fine detached granules surrounding esoph

    15. Glycogen Acanthosis - 2-3mm mucosal plaques over N esoph mucosa
    squamous cells w inc intracellular gllycogen, NO mallig potential
    seen in 15% of UGI & 100% post mortem

    Alcohol, Syphillis, Histo, and Behcet's syn also

    ESOPHAGEAL NARROWING
    CONGENITAL CONDITIONS

    1. Esophageal Web - thin mem w N mucosa, #1 at 2cm from pharn
    arises ant, never post, can be circumfrential
    rare dist webs assoc w reflux
    may see a jet of barium dist, sim a long stricture

    2. Schatzki Ring - lower esoph ring 2-3cm above diaph
    jxn between gastric & esoph mucosa
    if ring >12-13mm sx unlikely

    3. Tracheobronchial Rest - cartilage ring, seq from trach
    always dist, present in childhood w vomiting, asp, etc

    4. Congenital Stricture - incomplete occlusion, sm w prox dil


    NEOPLASTIC LESIONS - see section on filling defects
    fixed stricure, overhanging bulging edges, ulceration
    Esophogoscopy & Bx needed for Dx

    1. Squamous Cell Ca - most common mallig of esoph, 70%

    2. Adenocarcinoma - usually follows barretts's
    10% of stomach ca spreads to esoph, check cardia closely

    3. Mets - esp local ext & Nodes, usually a short seg
    any presentation possible, myenteric dest - achalasia
    Lymphoma - 10% involve esoph, nodular
    Mesothelioma & Breast - long segmental stenosis

    4. Benign Tumors - Leiomyomas #1, eccentrically narrow


    NONNEOPLASTIC CAUSES OF ESOPH NARROWING
    Tapered margins & smooth mucosal surface
    R/O diffuse spasm first

    1. Reflux - intense spasm & inflam
    II' strictures asym, Funnel shaped
    Barrett's - marked by cyclic ulceration and healing

    2. Corrosives - inflam, stricture as early as 2 wks
    Acid causes coagulative necrosis
    antrum of stomach #1 site of stricture P acid ingestion

    3. Iatrogenesis - post surg changes or post intubation
    NG tube allows inc reflux, stricture in 2 wks

    4. Infectious - stricture as part of healing inflam
    Candida - can have abrupt narrowing
    Herpes, Eosinophilic, Behcet's, Crohn's

    5. Radiation Injury - relativly radiation resistant
    >4000 rads, edema causes mucosal & muscle thickening
    Post radiation ca - most pt's don't live long enough

    6. Epidermolysis Bullosa - subepi blisters in mucosa
    stricture w healing, abrupt transition & webs common
    Cicatrizing permenant strictures can form

    7. Bullous Pemphigoid - mucosa of mouth & conjuctiva I', scarring
    mucosal edema & spasm, bullae erupt leaving ulcers

    8. Chronic Graft-vs-Host Dz - II' to donor lymphocytes
    allogenic bone trans, resembles bullous dz

    9. Sclerotherapy - may resemble ca w overhanging edges
    penetrating ulcers common

    10. Intramural Esophageal Pseudodiverticulosis
    90% assoc w sm stricture, 2/3 in upper, usually <10 tics

    ESOPHAGEAL FILLING DEFECTS

    MALIGNANT LESIONS

    1. Squamous Cell Ca - #1 Esophageal Tumor
    50% in mid, 30% dist, 20% prox
    infiltrating ca can burrow under mucosa, narrow lumen
    Risk Factors - alcohol, tobacco, reflux, hot tea & lye
    Tylosis - hyperkeratosis of hands & soles of feet
    Previous stricture, Achalasia & Plummer-Vinson syn (web)
    Freq assoc w head & neck Squamous cell, always check
    Progessive dysphagia #1 sx, Pain assoc w local spread
    Wt loss, Hoarseness from rec laryn Nerve involvement
    Chronic blood loss
    Findings - flat fixed plaque #1, can be fungating polyp
    progress to irreg narrowing, wide retrotrach stripe
    abrupt transition, overhanging margins, dest of folds
    cerv mass causes ant disp of trachea
    fist & sinuses common, use CT, thick wall irreg lumen
    Stage 1 - T1, stage 2 - T3N0, stage 3 - T3N1, Stage 4 - M1 T1 - submucosal, T2 - muscular layer, T3 - adventitia
    T4 - extention to contiguous organs
    Prognosis - 90% 5yr for muscosa only, rarely found early
    10% cured by rad therapy, palliative dilation also

    2. Adenocarcinoma - usually follows barretts's
    10% of stomach ca spreads to esoph, check cardia closely

    3. Mets - gastric extention common, Lymphoma usually II'

    4. Leiomyosarcoma - rare, usually bulky & ulcerated
    also called spindle cell squamous ca - spindles mix w sq
    may create a cupola

    Spindle Cell Carcinoma - Carcinosarcoma, mixed tumor
    Epithelial cells & Spindles, often lg & polypoid

    5. Melanoma - I' from basal cell layer, polypoid filling def

    6. Lymphoma - I' rare, usually II', nodular defect
    often ulcerates, may elongate & resem varices
    7. Kaposi's Sarcoma - systemic multifocal RES tumor

    8. Verrucous Carcinoma - occurs in stratified sqau epi
    Exophytic, papillary, or warty tumor, rarely mets

    9. Villous Adenoma - intermed malig, frondlike interstices


    BENIGN ESOPHAGEAL TUMORS
    <1% are benign, move freely during swallowing

    1. Leiomyoma - Prolif of Smooth musc sim to uterine, #1 Benign
    No malig transformation, No ulceration or bleeding
    Other GI sites have higher malig trans & ulceration
    Obtuse margins, amorphous calc diagnostic but rare
    Lobulated & elongated, mid-dist #1, huge at GE jxn
    Does not interfer w swallowing or motility initially

    2. Fibrovascular Polyp - adipose, stroma & fiber in mucosa
    Forms at mucosa just dist to cricopharyngeus
    traction at site initiates & elongates w swallowing
    can get lg w/o sx, dysphagia & pain
    Lg sausage shaped, slightly lobulated filling defect

    3. Inflammatory Esophagogastric Polyp - result of reflux
    hyperplasia of dist mucosa, usually pushed into stomach

    4. Papilloma - Epithelial prolif of unknown etiology, small
    can infil submucosal & thicken folds, sim varices
    Can also be mult & sim squa cell ca

    5. Granular Cell Tumor - rare, often in biliary or bronchus
    sm mural mass, may stimulate dysplasia of epithelium


    NON-NEOPLASTIC ESOPHOGEAL FILLING DEFECTS
    1. Varices - serpiginous mucosal masses, change w pressure
    can mimic neoplasm if thrombosed or single polyp
    see section on esoph varices

    2. Esophagitis - Infectious or Granulomatous
    Lymph node enlargement can create filling defects
    Candidiasis & herpes - mult round nod defects possible
    assoc ulcers & shaggy margins suggest Dx
    Crohn's - cobblestones or filiform polyps, rare
    Eosinophilic - may present as mult polyps

    3. Duplication Cyst - eccentric defect, muscle & mucosa
    less common than in remainder of GI tract

    4. Foreign Bodies - bones in cerv esoph #1, check 2 views
    poorly chewed meat etc lodges in dist, assoc w stricture

    5. Intramural Hematoma - post trauma to wall ie FB, scope etc
    anticoag pts, post sclerotherapy
    sudden onset dysphagia, hematemesis

    6. Hirsute Esophagus - follows reconstruction w skin

    7. Prolapsed gastric folds - usually spont reduction


    ESOPHAGEAL VARICES
    Gastric varices closely assoc
    Bleeding in sm varices as often as lg, 10% die immediate
    Use very thin barium, image during rest & horizontal
    complete filling may compress or obscure, unless thromb
    earliest in Rt ant lat, dist 1/3, use LAO
    forced or blocked insp will distend varices
    Probanthine 30mg will distend - antichol, bad w glacoma

    1. Portal Hypertension - collateral flow of portal blood
    coronary v to periesoph plexus to axygos to SVC
    Hepatic cirrhosis - #1, 90% dead in 2 yrs
    Ca of pancreas - obstructs portal or splenic veins
    pancreatitis, retroperitoneal inflam or fibrosis
    polycythemia - high viscosity
    Mets or primary Ca of the liver

    2. SVC Obstruction - due to tumor or inflam compression
    back flow thru azygos sys to periesoph plexus
    Thymoma or retrosternal Goiter
    Chronic fibrosing mediastinitis

    3. Heart Failure

    4. Varicele Mimics - thickened mucosal folds
    Lymphoma, most ca fixed, no change or peristalsis

    Sclerotherapy is accepted esp if portal shunt not an option

    DIFFUSE FINE NODULAR LESIONS OF ESOPHAGUS
    seen best on double contrast, exclude artifacts

    1. Glycogenic Acanthosis - N variant, 1-4mm linear nodules
    multifocal plaques of hyperplastic squamous epi
    scope only if appearance atypical

    2. Esophagitis - granular in early stages, any cause
    Candida & Herpes freq, often longitudinal

    3. Esophageal Ca - Superficial spreading type, submucosal only

    4. Acanthosis Migricans - premalig hyperkeratosis of skin
    Multiple verrucous prolif in esoph

    5. Leukoplakia - white patches of hyperplastic epi, mid 1/3

    6. Cowden Dz - multiple hamartomas, rare

    Hirsute esoph, extopic sebaceous glands, bullous pemphigoid

    ESOPHAGEAL DIVERTICULI
    1. Zenker's Diverticula - post midline at C5-6, pulsion type
    II' to motor discoordination of cricopharyngeus
    weak spot between obl & circular fibers
    food, mucous & drugs can accumulate, may compress esoph
    plain film may show widened retrotrach space w AF level
    oral contrast differentiates from abcess

    2. Traction Diverticula - II' to healing inflam or surg
    Thoracic diverticula - occur ant at level of hilum
    II' fibrous adhesions assoc w mediast lymph nodes
    LAO demonstrates best, look for calc nodes

    3. Lateral Diverticula - seen in cerv esoph of pts w dysphagia
    at pharyngoesoph jxn just below trans cricopharyngeus
    4. Epiphrenic Diverticula - dist 10cm, considered pulsion type
    Duplication with communication may be etiology
    assoc w motor abn, inc luminal pres, usually asym
    may dilate w food & mucous etc

    5. Diverticular Carcinoma - suspect ca if irreg, esp if previously smooth

    6. Intramural Esophageal Pseudodiverticulosis - sim tics
    represent rows of dilated submucosal glands
    flask shaped outpouching parrallel to long axis
    similar to Rokitansky-Aschoff sinuses of GB
    90% assoc w sm stricture in upper esoph
    may be II' to reflux, can be localized w fewer than 10

    ESOPHAGEAL RUPTURE
    1. Congenital Tracheoesophageal fistula - poor lumen dif
    common origin from caudal embryonic pharynx in 1st mo
    assoc w Tet, vert & rib anomalies, duod & anal atresia
    Type A fistula - both blind pouches, no air in stom, #2
    Type B fistulas - 90%, upper esoph ends in blind pouch
    lower seg con to trach, air in stom pathognomonic
    Type C fistula - H type, often asym, down from trach to esoph
    Type D fistula - upper con to trachea, no air in stom
    Type E fistula - both connect seperatly

    2. Acquired Tracheoesophageal Fistulas
    Malignancy - 50%, esp esoph ca, late & terminal complic
    Instrumentation - assoc w Ca, surg or caustic stric
    Trauma - assoc w severe substernal & back pain
    dysphagia & resp distress, plueral eff, hydropneumo
    Almost always ruptures to the LEFT
    Amylase may be detected in the resulting L pleural eff
    Boerhaave's Syn - usually at esophagogast jxn, no pulm
    epigastric pain radiating to shoulders
    present sweating, tachy, often in shock
    pneumomediast, eff in L base
    Caustic ingestion
    Inflam & granulomatous
    TB - eoph last organ effected
    usually direct errosion form mediastinal nodes
    Syphilis - assoc w syphilitic anuerysm
    Histo - assoc w nec nodes
    Actinomycosis - by local penetration or hematogenous
    Crohn's & Behcet's - rare
    Ruptured traction diverticulum
    Congenital Esophogeal Rupture - II' to pressure during delivery
    usually occurs post-medial & spills to R plueral space
    L side protected by aorta


    DOUBLE-BARREL ESOPHAGUS
    intramural dissecting channel

    1. Intramural Hematoma - compresses N lumen, may fill
    Use water solubles initially, but barium detects sm tear
    Emetogenic Injury - #1, mucosal tears from repeat cont
    Mallory-Weiss syn - bleed due to mucosal lac at jxn
    10% involve only esoph, men over 50 #1
    can occur w defecation, cough or lifting also
    Instumentation, bougies, trauma or anticoagulation

    2. Intramural Abscess - follows mucosal tear
    persistent pain, fever, dysphagia, no CXR findings

    3. Intraluminal Diverticulum - pocket open prox closed dist
    covered on both sides by mucosa, assoc w chronic inflam
    pulsion divertic restrained by muscle layer
    downward ballooning of partial esoph web also poss

    4. Esophageal Duplication - if communicating w lumen

    DIAPHRGMATIC HERNIAS
    1. Hiatal Hernia - most common finding on upper GI
    most sx & complications due to reflux
    volvulus w strangulation can be life threatening
    Organoaxial - greater curve rotates above lesser
    Mesenteroaxial - rotate on omental conections
    Lg hernias lead to resp compromise, CXR may detect
    Schatzki ring - transition between esoph & gastric muc
    helps define extent, double ring sign

    2. Paraesophageal Hernia - stomach herniates ANTERIOR to esoph
    thru hiatus or adjacent gap, not assoc w reflux
    Varices - develop due to lymph & venous obs
    Bleeding much worse than in esophageal hiatal hernia
    Usually repaired, serious complication potential
    asym unless lg, resp probs, volvulus

    3. Foramen of Morgagni Hernia - anteriomedial, greater on RIGHT
    Present in adults II' to obesity or trauma
    if no bowel, resembles pericardial cyst, pulm hamartoma

    4. Foramen of Bochdalek Hernia - postlateral, LEFT due to liver
    75% symptomatic, chest & back pain, dyspnea
    Congenital hernias usually occur here - no hernia sac
    abd organs enter before septum transversum closes
    resembles cystic adenomatoid formation in lung
    severe hernias may have no gas in chest, thin abd

    5. Traumatic Diaphragmatic Hernia - usually direct laceration
    Blunt also, 90% occur on L, Sx often develop years after
    Seen on plain film, sim paralysis, moves w pt position

    6. Intrapericardial Hernia - rare, congenital or post trauma

     

    Stomach

    BENIGN GASTRIC ULCERS
    Penetration beyond N lumen key
    Submucosa more rapidly destroyed than mucosa, undermines
    Hampton Line - thin sharp line at ulcer base
    Ulcer Collar - seperates ulcer from lumen
    Ulcer Mound - ext mucosal edema, dec distensability
    can simulate ca, symetric w ulcer in center though
    Crescent sign - edema nearly obliterates neck
    Antral Diverticula - simulate crescent sign
    Mucosal folds Radiate to edge of ulcer, smooth & narrow
    Halo sign - wide lucent band of symetric edema
    mucosal folds seen up to edge, pathognomonic benign
    hazy indistinct borders rather than sharp transition
    Size & location are not helpful, except fundus - malig
    benign most common on lesser curve & post wall
    Ellipse sign - if parrallel to long axis it's an ulcer
    if perpendicular it's nonulcerated deformity
    95% heal 1/2 in 3wks, complete in 6wks w medical manage
    stiffened wall, persistent converging folds
    Endoscopy not needed unless atypical

    1. Peptic Ulcer Dz - #1 by far, dist in young, prox in old
    Marginal Ulceration - post-op comlication of PUD surg
    in jejunum 2-3cm from anastamosis, 2-4 yrs out

    2. Benign Tumors - Leiomyoma etc

    3. Inflam & Granulomatous Processes
    4. Radiation Injury - >4500 rads, occur from 1mo to 6yrs P
    pain is often unrelenting w no relation to meals
    Inc incidence of perforation & hemorrhage, rare healing

    5. Pseudolymphoma - Gastric lymphoid hyperplasia
    nonspecific late rxn to chronic PUD, mimics malig type
    regional enlargement of rugal folds

    6. Hepatic Arterial Infusion Chemotherapy - toxic to lining
    esp if cath moves into L gastric art


    SUPERFICIAL GASTRIC EROSIONS
    do not penetrate beyond muscularis mucosa
    seen on upper GI approx 50% w air contrast

    1. Dyspepsia #1 - 20% bleed, barium won't coat, endoscope
    Barium shows fleck & halo, edema around erosion
    Incomplete erosions appear as flat epithelial defects
    assoc w NSAIDs, rarely aligned w rugal folds
    greater curve & antrum due to gravity

    2. Aphthoid ulcers - small targets
    Crohns - earliest asym stage, noncaseating granulomas
    Alcohol, candida, syphilis, CMV also

    3. Lymphoma - can appear as tiny ulcers in nodular folds
    GASTRIC MALIGNANCIES
    Represents a necrotic region in mass, abrupt transition
    Remains within the expected confines of N gastric lumen
    Nodular center w irreg or amputated radiating folds
    Carman's Minescus - semicirc collection convex to lumen
    Kirklin complex - elev ridge surrounding a carman ulcer

    1. Adenocarcinoma - 90%, poor prognosis because sx late
    Risk Factors - Same as for Gastritis, 2:1 male
    achlohydria, pernicious anemia, polyps
    Expansile Type - villous, well-differentiated
    Assoc w intestinal metaplasia
    Infiltrative Type - Scirrous Carcinoma, poorly diff
    Signet ring cells w INTRAcellular mucin, antrum>body
    infiltrates into submucosa causing narrowing & rigidity
    CT - thick wall w extensive desmoplasia, extention
    Mucious Adenocarcinoma - subtype w EXTRAcellular mucin
    also poorly diff, freq punctate calc, submucosal infil
    Carcinoma in Situ - limited to submucosa, improved prognosis Pain & wt loss, occult bleeding common
    30X greater in japan, iceland & chile

    2. Lymphoma - 2%, usually NHL met, almost never Hodgkin's
    I' when presents in GI or local node w NO dist nodes
    Variable grades of tumor do not predict response to Tx
    Presents in ileocecal valve in child, intussusception
    Stomach #1 in adult
    Origin from mucosal lyphoid B-cells in 80%
    Polypoid, Nodular or diffuse thickening of folds poss
    Minimal desmoplastic Rxn, Freq cental ulceration, mult 25%
    Rarely obstructs, more often dilates lumen
    Mets often assoc w enlarged spleen & extrinsic comp by node
    DDx - Adenoca cannot be excluded, more fibrotic, obstructing

    Pseudolymphoma - actually just a low grade infil of lymphoma
    Ulcerating mass or thickened folds sim

    3. Sarcoma - rare, develop lg ulcers, sim to benign forms
    Leiomyosarcomas, lipo & fibrosarcoma, neurogenic sarcoma

    4. Mets - hematogenous melanoma #1, Bull's eye lesion
    5. Carcinoid - from Kulchitsky cells in crypts of Lieberkuhn
    precursor neuralectodermal cells, rare in stomach
    assoc w hyperacidity due to histamine prod
    slow growing, long survival even w distal mets

    NARROWING OF THE STOMACH
    Linitis Plastica Pattern - leather bottle stomach

    MALIGNANT CAUSES
    1. Adenocarcinoma, Infiltrative Type - Scirrhous Carcinoma #1
    infiltrates thru submucosa
    no peristalsis beyond Ca, pyloris then spreads prox
    Nodular thickening, stage w CT

    2. Hodgkin's Lymphoma - invasion can cause desmoplastic rxn
    Antral, mucosa effaced but intact, peristalsis retained
    Assoc w lg nodes, speenomegaly, poss lobulated mass

    3. Mets - Pancreas extention #1, nodes or trans colon also
    Mucosa often intact initially, spiculated pattern later
    Hematogenous spread from breast

    BENIGN CAUSES - rare
    R/O extrinsic compression narrowing lumen, esp hepatomeg

    1. Gastric Ulcer Dz - intense spasm may hide ulcer
    High ulcers in older pt may heal w Hourglass deformity

    2. Infection - edema & inflam, smooth thickening, antral pred
    Syphilis - tertiary, scattered gummatous polyps
    TB & granulomatous processes - ulceration & fistula poss
    Eosinophilic Gastritis - infil of eosinophils, outlet obs
    resolves w steroid Tx, follows allergy to food
    Polyarteritis Nodosa related
    Phlegmonous Gastritis - bacterial invasion, submuc edema
    Strep #1, E. coli, clostridium, proteus also
    Purulent emesis pathognomonic, extreme pain, fever
    Emphysematous gastritis - air in wall, LETHAL
    Stongyloides Stercoralis - invades wall
    CMV - AIDES pts can have advanced cases
    3. Crohn's Dz - narrow antrum, slow peristalsis, cobblestones
    doudenum involved giving a bilroth-I type pattern

    4. Sarcoidosis - 10% have stomach involvement, usually antral
    may mimic ca, pain, thickened folds, bleeding
    extensive adenopathy assoc, must Bx for Dx

    5. Corrosive Agents - esp Acids due to coagulative necrosis
    acute inflam heals by fibrosis, sim to malig
    Antrum of stomach most common site of stricture
    Iron Intoxication - usually children, intense corrosive
    Hepatic art Chemo - tends to resolve P tx stoped

    6. Radiation - >4500 rads, usually not in tx fields
    Achlorhydria - reduces parietal cell pop

    7. Stenosing Antral Gastritis - inflam efaces folds, sim ca
    spasm may be caused by myenteric damage

    8. Amyloidosis - protien polysaccaride complex deposites

    9. Peudolymphoma - hyperplasia, linitis assoc w lg ulcer

    10. Intramural Gastric Hematoma - compresses lumen, FUNDUS
    Submucosal mass simulating a mesenchymal tumor

    11. Gastric Partitioning - get Hx

    12. Perigastric Adhesions - circumfrential antral narrowing
    Mucosa remains intact, peristalsis N

    THICKENING OF GASTRIC FOLDS
    Magenstrasse - folds of lesser curve channel fluid to duo
    Lamina propria, muscularis mucosa & portions of submuc
    edema or inflam of any layer can effect folds
    Antral folds >5mm abnormal, Fundal folds thicker
    Areae Gasticae - N anatomic folds most prom in antrum
    no known physiologic fxn, prom in inflam & hyperplasia

    BENIGN CAUSES
    1. PUD - #1, fold size in body & antrum assoc w acid level
    Most II' progresion from Gastritis

    Zollenger-Ellison Syn - acid prod II' to gastrinoma
    Glandular hyperplasia & hyperchlorhydria
    Lg amounts of retained gastric fluid, PUD in 75%
    Fold thickening extends to duo & sm bowel
    Esoph stricture due to GERD also assoc
    25% assoc w MEN-I - Panc, Parathyroid, Pituitary

    2. Gastritis - Helicobactor plays a role in all
    99% of duodenal ulcers, Tx w Abx, Flagyl & bismuth
    Acute Gastritis - #1 exogenous cause, resolves change
    Etoh, ANSAIDS, bile, ischemia & acidosis predispose
    UGI - mild fold thickening, incomplete erosions
    Endoscope see much better due to pale appearance
    Chronic Gastritis - plasma cell infil into lamina propria
    Nodular filling defects from heaped up plasma cells
    Heals slowly, may remain for years, Antrum > Body
    Hypertrophic Gastritis - hyperplasia II' to chron inflam
    assoc w inc secretions, freq ulcers
    Prominent areae gastricae, 4-5mm & angular, N 1-2mm oval
    Fundal Gastritis - Ab to parital cell & intrinsic factor
    often asym, pernicious animia poss, assoc w achlorhydria
    Intestinal Metaplasia - mucosa trans to villiform
    inc incidence of adenoma's & adenoca
    Atrophic Gastritis - chronic progression, loss of folds
    tubular narrowing & loss of mucosal glands
    Antral Gastritis - localized to antrum w no dou involved
    flattening of the prepyloric shoulders, corregated muc
    persistent pain unchanged by antacids or eating, Helicobactor freq
    3. Hyperplastic Polyps - 90% of gastric polyps, non-malig
    Often assoc w adenoca due to common link w Gastritis
    Usually Antral, <1.5cm & line up along rugal folds
    Tx for Helicobactor often causes complete regression
    DDx - Menetrier Dz & Villous Tumor, Dx w Bx
    hanging drops can sim ulceration of melenoma etc

    4. Menetrier Disease - Idiopathic mucosal hyperplasia, Helico?
    Foveolar hyperplasia - abn tight jxn's, protien leaks out
    Hypoprotienemia - Edema, ascites, rash & diarrhea
    Glandular Hyperplasia - leads to achlorhydria
    UGI - Bizarre giant rugal fold thickening, esp at greater C
    Sluggish peristalsis, slight premalig potential, Antrum often spared
    CT - IV bollus shows epithelial enhancement, mucosa low atten
    DDx - protien loss also w atrophic gastritis & gastric Ca

    Pediatric Hypertrophic Gastropathy - sim protein loss
    Prox stomach only, follows GI or resp viral prodrome

    5. Gastric Varices - assoc esoph varices, very pliable
    Dil short & L gastric veins empty to coronary v of stom
    if portal v patent, less varices
    No Esoph varices pathognomonic of Splenic v occ

    6. Infectious - hyperemia of stomach II' to bacteria or toxin
    Anisakis - viceral larva migrans from raw fish, nematode
    acute pain in 4-6 hrs P ingestion, self-limited
    Pencil-like filling defects 30mm long
    CMV - diffuse gastritis w thick nodular folds
    differs from Kaposi's nodules, no diffuse gastritis
    Eosinophilic infil
    Granulomatous processes - TB, Crohn's, sarcoid, Syphilis
    seen before characteristic antral narrowing

    7. Corrosive agents - intense mucosal edema & inflam
    assoc w ulceration, atony, rigidity
    fixed open pyloris, free air in wall is bad
    fluids follow magenstrasse & accum in antrum
    tetonic contraction prevents further passage

    8. Radiation - >4500 rads, not often included w lower abd

    9. Pancreatic Dz - greater curvature, often w pseudocyst
    direct metastatic ca spread also


    NEOPLASTIC CAUSES OF THICKENED FOLDS
    1. Lymphoma - fold enlargement often in proximity to mass
    assoc ulceration & loss of pliability, Lukemic infil sim
    Pseudolymphooma - benign prolif, even histo misleading

    2. Adenoca, Mucinous Type - occasionally as lg tortuos folds
    preserves realitivly N gastric vol & peristalsis, Bx Dx
    Punctate calc may be assoc - Mucinous or colloid ca
    Pathognomonic, similar to Psammoma bodies in thyroid

    FILLING DEFECTS IN THE STOMACH
    Areae Gastrica - N on all air-contrast, usually antral
    Glucagon, thick barium give best results
    indicates thinner mucus, prone to ulcers possibly
    prominence assoc w hypertrophic mucosa, ie inc PUD

    1. Polyps - usually asym, may bleed, or prolapse w outlet obs
    3 Types, both can be seen w adjacent ca

    Hyperplastic Polyps - #1 loc filling defect, 90% of gastric polyps
    NOT malig, excess epi regeneration in response to inflam
    hyperplastic glands, often cystic, rare mytosis
    multiple & randomly scattered, Uniform 1-2cm & smooth
    Bx unless multiple and uniform in older pt, 7% assoc w Ca

    Adenomatous Polyps - dysplastic glands, Premalig
    Lg w irreg lobulated surface, inc size = inc malig
    single & antral, sessile or peduculated
    Papillary w freq mytosis, inflam changes NOT prom
    Tubular Type - smooth but lobulated, antral
    Villous Type - Irreg interstices, inc malig trans
    most have Ca in situ at time of Dx

    Cronkhite-Canada Syn - juvenile type polyps, presents in elderly, F>M
    alopecia, onychodystrophy, hyperpigmentation & malabsorbtion
    100% have polyps in stomach & colon, >50% in small bowel
    hamartomas w no malig potential, protien losing enteropathy

    Familial Colon Polyposis - inc stomach polyps as well

    Gardner's Syn - stomach polyps in <5%, inc risk of ampullary Ca in 12%
    2. Hamartomas - N mucosa arranged differently
    Peutz-Jeghers syn - Sm bowel polyps, mucocutatneous pig
    No malig potential
    Cowden Dz - hamartomas thruout GI, circumoral papillomas
    Ruvalcaba-Myhre-Smith syn - thruout GI, macrocephaly
    pigmented genital macules, retard, subQ lipomas

    3. Gastric Duplication Cyst - Rare, contain all layers
    usually Dx at infancy, vommiting, anemia
    usually no communication but bleed & perf
    Greater curve

    4. Adenoca, Expansile Type - arise de novo or from polyp
    Anemia & epigastric pain #1, often asym
    Assoc w pernicious anemia & atrophic gastritis
    Consider malig if sessile & >2cm
    Mucinous Adenocarcinoma - assoc w granular calc

    5. Lymphoma - multiple ulcerating polypoid tumors typical
    Pseudolymphoma - benign prolif which mimics

    6. Mets - Melanoma #1, bull's eye app, always w sm bowel also

    7. Spindle Cell Tumors - 80% of benign gastric neoplasms
    any size, usually asym, ulcerate as enlarge, 5% w calc
    intra or exogastric forms, can mimic ext compression
    Leiomyoma - matted sm muscle w vasc collagen stroma
    Lipomas, Hemangiomas, Fibromas & Neurogenic tumors

    Sarcoma - rare in stom, arise intramural, present luminal
    bulky w extensive cent necrosis, extensive local spread
    diff from leiomyoma by lg exogastric mass
    Spread to liver & lung, node involvement rare
    Leiomyoblastoma - slow growing, from sm muscle, antral
    Kaposi's Sarcoma - coalescing nodules in submucosa
    Smooth w no ulceration

    8. Carcinoid Tumor - from precursor neuroectodermal cells
    sessile polyps or broad based filling defect
    local invasion or hepatic mets, slow growing, long surv

    9. Plasmacytoma - much more common in sm bowel
    in stomach usually assoc w multiple myeloma in pt >50
    INFLAMMATORY & EXTRINSIC FILLING DEFECTS
    can mimic intramural & luminal masses

    1. Ectopic Pancreas - most common in greater curve, <2cm
    50% symtomatic w vague pain, nausea

    2. Enlarged Gastric Folds - esp menetrier's, crohn's, TB
    Gastric Ulcers w assoc edema
    Hypertrophied Antral Pyloric fold - extends antrum to duo
    assoc w chronic gastritis, fixed unlike antral prolapse

    3. Bezoar - mottled appearance, assoc w ulcers
    Phytobezoar - veg, esp persimmons which coag in acid
    Trichobezoars - hairballs, esp schizo women
    FB or gallstone can cause ulceration

    4. Hematoma - either intramural or clot sitting in fundus

    5. Double Pylorus - gastroduodenal fistula, lesser curve
    assoc w PUD, N mucosa between sim a filling defect

    6. Eosinophilic Granuloma - not assoc w bone form or allergy
    Sessile smooth polyp, pt usually asym
    Localized form, almost exclusively in stomach

    Eosinophilic Gastroenteritis - diffuse form, infil of all layers poss
    Hx of systemic or food allergy, present w pain & diarhea
    involves dist stomach & entire sm bowel esp jejunum
    marked thickening if muscle involved, ascites if serosa involved
    assoc w peripheral eosinophilia (gastric Loffler's syn?)

    7. Arterial Impression - Splenic on post med wall

    8. Extramedullary Hematopoesis - esp w chronic myelogenous L

    9. Amyloidosis - mult sm defects, usually w diffuse GI invol

    10. Candidiasis - mult nodules w central ulcers, bull's-eye

    MASSES OF THE FUNDUS
    above horizontal line from esophagogastric jxn
    adjacent to L liver, diaph & spleen

    1. Neoplasms - benign can mimic malig
    Adenocarcinoma - nodular, ulcerate freq, prox to esoph
    may see a deformed gas bubble on upright film
    Lymphoma - stom body often assoc as well, rare esoph ext
    Leiomyosarcoma - rare, lg w central ulceration
    Pancreatic or splenic flexure tumors often extend
    Celiac nodes - compress central fundus

    2. Normal structures - 70% of impressions benign, transient

    3. Non-neoplastic
    Esophageal prolapse - erosion & bleeding assoc
    Hiatal hernia - redundent tissue when reduced
    Varices - diff to distinguish alone, post & postmed wall
    cirrhosis, splenomegly, esoph varices assoc
    Thick Rugae - make sure well distended
    Splenectomy defect - II' to short gastric art ligations
    splenules grow later, poss in stomach wall
    Subphrenic abcess, Hematoma, unfilled polyp also

    MISCELLANEOUS STOMACH PROCESSES
    GASTRIC REMENANT COMPLICATIONS

    Bilroth I - gastroduodenostomy, Bilroth II - gastrojejunostomy
    works due to the removal of most of the gastrin secreting cells

    1. Marginal Ulcers - usually develop in jejunum, efferent loop
    Assoc w retained antral seg, freq perforation
    lg marginal ulcerations seen w Z-E syndrome

    2. Bezoar - common in both I & II due to dec pepsin & acid
    Stoma size has no bearing, usually up to 4cm
    can cause outlet obs or pass to sm bowel, obs ileum
    inadequate chewing assoc w poor dentition

    3. Gastric Stump Carcinoma - Much more common w Bilroth II
    20% develop in 20 yrs, even if done for benign causes
    chronic bile & panc reflux prob accounts for this
    Barium demonstrates poorly, Always need baseline
    Recurrent Ca - usually considered a 2nd I' if >10 yrs
    Lymphoma - retains pliability
    any ulcer should raise suspicion

    4. Hyperplastic Polyps - response to bile & panc reflux
    Suture granuloma - round defect at anastamosis
    only w non-absorbable suture

    5. Jejunogastric Intussusception - rare but lethal
    Jejunum enters stomach, eff loop 75% of the time
    Chronic form is possible
    Glucagon & barium can aide in reduction
    Gastrojejunal prolapse more common, obs if large

    6. Macrocytic Anemia - any process which removes antrum or ileum
    Also caused by bacterial overgrowth in blind loop


    GASTRIC OUTLET OBSTRUCTION
    1. Peptic Ulcer Disease - 60%, usually in the duo, bileous
    pylorus & dist antrum also but rarly body
    Spasm, inflam, edema, scar contracture, stom distended
    vomiting, delayed 1-2hrs, relieves the constant pain
    scarring of bulb w pseudodiverticula indicates benign
    N bulb more suspicious of malig
    2. Malignant Tumors - annular ca of antrum, 30% of cases
    often no pain or pain less than 1 yr, vomiting & wt loss
    Scirrhous Carcinoma of pylorus identical to benign stric
    invades submucoasal & musc layers, preserves mucosa
    early met, duo usually spared & N in appearance

    3. Benign Tumors - rare, prolapse of antral polyp
    filling defect in bulb, may reduce easily

    4. Inflammatory Disorders - infiltration or spasm of antrum
    Crohn's Dz of stomach - 2/3 of pts develop this
    Granulomatous - rare
    Pancreatitis & cholecystitis - inflam spasm of duo
    corrosives & amyloid also

    5. Antral Mucosal Diaphragm - membranous septa 3cm from pyloris
    Congenital - failure of embryonic forgut to canulize
    Fibrosis cause also postulated II' to PUD
    Asym if opening >1cm, 2mm seen asym until adulthood
    may see jet effect, can mimic a 2nd duo bulb

    6. Gastric Duplication - may narrow and deform the antrum

    7. Annular Pancreas - compresses lat descending duo

    8. Gastric Volvulus - rare, assoc w lg hiatal hernia
    Organoaxial - rotation around the long axis
    Mesenteroaxial - rotates on gastrohepatic omentum
    Sx vary from none to surgical emergency
    Vasc occ assoc w 30% mortality
    Double AF level seen on upright films

    9. Hypertrophic Pyloric Stenosis - infantile or delayed adult
    adult don't have high grade, 50% assoc w ulcers
    retained semisolid food causes secretion of gastrin & acid = PUD
    spasm caused by PUD exacerbates
    Pyloris elongates to 2-4cm, invaginates into bulb
    can sim scirrhous ca or Pylorospasm on UGI
    Torus Hyperplasia - focal hypertrophy at lesser curve
    greater curve develops serrations
    Sonography - muscle layer >3mm anechoic rim
    length greater than 17mm
    central echogenic center of mucosa & submucosa


    GASTRIC DILATATION WITHOUT OUTLET OBS
    vommiting of food eaten more than 6hrs earlier
    food present during UGI, poor peristalsis

    1. Acute Gastric Dilation - can occur in minutes to hours
    vomiting, dehydratin, periph vasc collapse
    Post-op #1, less w NG suction, etc
    Inflammatory peritoneal proc via reflex motor neuro path
    Immobilazation or pain due to difficulty belching
    Pain seldom severe until cyanosis occuring

    2. Chronic Gastric Dilation - 30% of diabetics
    Poor control = autonomic neuropathy, ketoacidosis worse
    Vagotomy w/o emptying procedure has sim app, CNS also
    Scleroderma - rare, diffuse hypotonia can develop
    polymyositis, dermatomyositis, myotonic musc dystrophy also
    Electrolyte & acid-base imbalances alter musc tone
    Lead poisoning, hyperventilation also

    WIDENING OF THE RETROGASTRIC SPACE
    lesser sac lies between stom & vert body
    Pancreatic neck 1-1.5cm thick, aortic nodes & aorta
    No set width, impression on stom must be demonstrated

    1. Benign Causes - Obesity #1, retroperitoneal fat
    Post-op adhesions or disruption of N ligaments
    Ascites & gross hepatomegaly

    2. Pancreatic Masses - Pancreatitis, Pseudocyst, cystademoma
    Head lesions compress post inf antrum
    Body & tail lesions compress body & fundus of stom
    Panc ca fixates wall, ulcerates

    3. Other Retroperitoneal Masses - Sarcoma, renal & adrenal ca
    Lymphoma & nodes, TB, cysts, abcess
    Hematoma or aortic aneurysm
    Leiomyomsarcomas - Lg exogastric component


    GAS IN THE WALL OF THE STOMACH
    Sx of other underlying disorder
    mottled shadow of bubbles fixed in wall
    Not diagnostic, represents breach of epi

    1. Emphysematous Gastritis - severe phlegmonous gastritis
    Strep, clostridia, anerobics
    Severe pain, hematemesis, rapid progression to death
    Mucosa seperates early, cicatricial stenosis results
    Rupture & gastric sinus tracts also

    2. Severe necrotizing Gastroenteritits - assoc w PUD

    3. Corrosives - penetration of mucosa

    4. Ischemia - esp assoc w overdistention

    5. Trauma - II' to endoscopy, gas pattern linear not mottled

    6. Rupture of Pulm Bullus into esoph mucosa
    consider if pt is not sick


    INVOLVEMENT OF THE ANTRUM & DUO BULB
    1. Malignant Lesions - ext to bulb pathognomonic of lymphoma
    Adenoca causes outlet obs before bulb involved in 95%
    Adenoca still more likely, 50X greater occurance

    2. PUD - thickening & ulceration freq in both, fibrosis also

    3. Crohn's Dz - blends antrum, pylorus & bulb into a funnel
    Pseudo-bilroth I pattern, remains distensable
    mucosa can become shaggy & nodular

    4. TB - dou involved in 10% of gastric cases, 50% w pylorus
    Stomach TB rare even w intestinal or pulm involvement

    5. Strongyloidiasis - nodular intramural def, ulcer, strictur

    6. Eosinophilic Gastroenteritis - contiguous fold thickening
    Assoc w peripheral eosinophilia & food allergy.

     

    Duodenum

    ULCERATION OF THE DUODENUM
    1. PUD - only 5% in postbulbar region, 7:1 male
    Postbulbar more likely to bleed (66%), rarely perforate
    Medial wall prox to ampulla of vater #1 (ant wall for bulbar ulcers)
    freq incisura on opposite wall, "kissing ulcer"
    may cause obs, pancreatitis, bleeding, pain
    Shallow flattened niche in med aspect, lat rare
    Incisura produced by lat spasm, can persist to fibrosis
    Ring Stricture - chronic & progressive, indicative PUD
    assoc w severe Sx
    Can penetrate to pancreas, pancreatitis, ext compression

    2. Zollinger-Ellison Syn - Gastrinoma, most in panc, 2/3 mult 10% in duo
    25% of ulcers occur postbulbar, always consider w ulcers dist to ampulla
    assoc w fold thickening thruout, hypersecretion
    Ulcers fail to respond to traditional therapy
    one develops while a 2nd heals, recur P surg resec

    3. Malignant Tumors - #1 cause of non-PUD ulcers
    Adenocarcinoma #1 in duo, Lymphoma & Sarc can also ulcer
    Spread from panc, colon, R kid, GB
    Melanoma - hematogenous mets, massive hemorrhage

    4. Benign Tumors - lieomyomas can ulcerate

    5. Granulomatous Dz - Crohn's assoc w other GI involvement
    TB - assoc w severe spasm & mucosal edema

    6. Aorticoduodenal Fistula - assoc w aneurysm & post reconst

    7. Pseudoulceration - ectopic pancreas can retain barium
    Sm diverticula - maliable, no fold thickening

    THICKENING OF DUODENAL FOLDS - >5mm
    Can create a "Psuedokidney" sign on US

    INFLAMMATORY DISORDERS
    edema of mucosa or submucosa layers thickens folds

    1. PUD - #1, Mucosal edema causes compresable folds
    Hyperplasia of Brunner's glands, fixed nodular folds

    2. Zollinger-Ellison Syn - assoc w thick gastric rugae
    ulcerations distal, 3rd & 4th duo & prox jej

    3. Duodinitis - may be more freq cause of pain than ulcers
    Hyperactive peristalsis, nodular thickened folds
    no assoc ulceration, inc incidence w renal Dz

    4. Pancreatitis & Cholecystitis - spasm can prevent filling
    Periampullary & prox 2nd duo, elev amylase, ext comp

    5. Infectious - TB would also have assoc pyloric & antral Dz
    Whipple's Dz - mostly jej (see pg74), infil w PAS pos macrophages
    II' to bacteria, all sys involved, arthritis freq
    thick pliable folds, NO dilation, NO ulceration
    Giardiasis & Strongyloidis - hypersecretion & motility
    AIDS - allows mult bugs to induce inflam

    6. Uremia - chronic dialysis assoc w nausea & vomiting
    Bulb & 2nd portion get irreg stiffened folds
    Inc PUD but thick folds not related to hyperacidity

    7. Crohn's - may be isolated to duo

    8. Sprue - thick folds, marked dilation

    9. Cystic Fibrosis - low panc bicarb allows acid damage
    fold thickened esp in bulb & 2nd portion
    NEOPLASTIC CASUSES OF DUO FOLD THICKENING
    Lymphatic Blockage - II' to nodal mets or local extention
    Lymphoma & Kaposi's sarcoma also


    VASCULAR CAUSES OF DUO FOLD THICKENING
    1. Duodenal Varices - obs of portal or splenic, 4 forms
    1) flow in sup pancreaticoduodenal vein compresses bulb
    2) Sm varices prod diffuse polypoid mucosal pattern
    3) Lg submucosal vein cause serpig filling defects
    4) Isolated dou varix on med descending side, rare
    Always assoc w Esoph varices

    2. Mesenteric Arterial Collaterals - celiac or sup mesen obs
    Pancreaticoduodenaal arcade lies adj to dec duo
    Gastoduodenal also at variable distances
    can prod lg defects & widen sweep
    Aberent R Hepatic from sup mesen - defect on sup bulb
    Chronic congestion leads to edema of wall, dyspepsia

    3. Hematoma - folds in a "stacked coin" config, anticoag etc

    WIDENING OF THE DUODENAL SWEEP
    common N variant esp in fat pt w high trans stomach

    1. Acute Pancreatitis - usually II' to Etoh, pain always
    panc head may be 3X N size, smooth mass on inner sweep
    Paresis & edema of folds & papilla of vater
    Displaces greater curve as well, gastric atony & dil
    Elev hemidiaph, L eff, sentinel loop, colon cut-off
    CT to R/O phleg, pseudocyst etc
    Ultrasound - hypoechoic

    2. Chronic Pancreatitis - 50% assoc w Etoh, 30% w calc
    Malabsorbtion, wt loss, aseptic nec
    Fold effacement II' to fibrosis & rigidity of the wall
    Spiculated mucosa, enlarged papilla
    US - hyperechoic, calc shadows, duct dil II' to fib
    3. Psuedocyst - no epi lining of a true cyst
    panc fluid exudes into tissue, osmolality pulls in fluid
    reactive fibrosis forms wall, those in head widen sweep
    70% form in body & tail post to stom
    assoc parenchymal calc freq
    US - hemorhage into cyst can create complex echos
    Infection can occur, rupture into peritoneum poss fatal

    4. Pancreatic Head Ca - widening indicates advanced Dz
    Antral pad sign - indention on dist greater curve
    Double-Contour effect - indention of inner aspect of duo
    Inverted 3 sign - comp w fixation of the papilla
    more common w inflammation
    Spiculation of mucosa - also w inflam but suspicious
    Irreg Nodularity more specific to ca
    US - demostrates tumors >2cm in head
    CT - tumors relatively avasc, less enhance than N gland
    most important for staging & Bx guidance
    often encase & obs vessels

    5. Mets - local ext into panc head from stom, colon, kid
    Hematogenous mets to panc head rare
    Nodes - pyloric nodes lie inf to bulb & 2nd portion
    Pancreatoduodenal nodes between panc & duo

    6. Cystadenoma & Cystadenocarcinoma - usually body & Tail
    Occur in younger pt than ca, mostly women, asym
    High assoc w endocrine abn, thyroid, diabetes, obesity
    excision often curative, can grow very lg

    7. Aortic Aneurysm or Dilated Lymph Ducts - disp 3rd portion
    Choledochal cyst - in child <10 y/o, see below

    EXTRINSIC PRESSURE ON THE DUODENUM
    all organs of the R upper quad can effect duo

    1. CBD - produces linear imp on bulb, R sup
    Choldochal Cyst - segmental dil of CBD, 60% pts <10 y/o
    triad of jaundice, RuQ mass & pain classic but rare
    can widen sweep

    2. GB - imp on upper outer margin of bulb & sweep
    Hydrops of GB - dist II' to acute or chronic obs
    occurs in children
    Courvoisier Phenomenon - enlargment w jaundice
    usually indicates a malig extrahepatic obs
    GB carcinoma - rare, inc in elderly women
    freq seen w calc GB wall, can displace & ulcerate duo
    Abscess II' to chlecystits can disp or cause dou edema

    3. Liver - disp bulb & sweep Leftward, esp caudate
    anomalous lobe or nodes in periportal region also

    4. R Kidney & Adrenal - imp on post lat sweep
    Cysts, renal cell, addisons, etc

    5. Pancreas - nodule in lat 2nd portion, ca or annular
    post bulbar PUD produces identical app, lat Incisura

    6. Colon - mutual indention N in 30%, ant
    duodenalcolioc fistulas can develop

    7. Vascular - see sec on thickened folds

    DUODENAL FILLING DEFECTS
    R/O Pseudotumors - GB, ulcer mound, FB, stich abcess, tic
    barium in biliary tree suggests gallstone

    NONNEOPLASTIC MASSES
    N mucosal folds can be redundent, esp at flexure

    1. Erosions - sm flecks of barium assoc w PUD or Crohns
    improperly mixed barium powder can prod this effect
    Nonerosive Duodenitis - #2, velvety thickening of folds
    not assoc w PUD or hypersecretion

    2. Brunner's Gland Hyperplasia - mult nodular filling defects
    mixed serous & mucous acinar lobules, may extend to jej
    usually only 1st part of duo in response to PUD

    3. Benign Lymphoid Hyperplasia - innuberable tiny nodules
    usually not the nodular type, no assoc w lymphoma
    assoc w dysgammaglobulinemia in children

    4. Heterotopic Gastric Mucosa - elevated lesions 1-6mm
    most in immediate post pyloric region

    Ectopic Pancreas - discrete defect in prox 2nd, incidental
    Pancreatic rests #1 in dist stom along greater curve
    central dimple of panc duct often seen

    5. Sprue - 1-4mm hexagonal filling defects in bulb
    Flattens villi, exposes Brunner's glands
    Gluten hypersensitivity

    6. Prolapsed Antral Mucosa - lobulated defect at base of bulb
    reduction reveals redundant folds

    7. Choledochocele - cystic dil of CBD at ampulla
    smooth def, projects into lumen on med wall

    8. Dulplication Cyst - usually seen early, 10% communicate
    fluid filled, seen in concavity of 1st & 2nd portions

    9. Vascular Structures - varices, arterial coll
    Hematoma - 80% in children & young adults, coiled spring
    retroperitoneal 2nd & 3rd portions fixed
    crush between vert & abd wall, anticoag, post Bx, etc
    BENIGN NEOPLASTIC CAUSES OF DUO FILLING DEFECTS
    90% of bulb tumors, 4th portion 90% malig
    50% of 2nd & 3rd portion benign, most asym & solitary
    may ulcerate & bleed, may obstruct papilla
    smooth appearance often does not exclude malig

    1. Adenoma - #1, 1cm smooth polyp, often pedunculated
    Brunner's Gland Adenoma - local hypertrophy, not neoplasm

    Villous Adenoma - more common than tubular in duo
    Periampullar #1, usually 2-3cm, Tx w resection
    Can grow into ampulla & obs both causing jaundice
    Frondlike lobulated defect w fine interces, changeable
    Not assoc w mucorea or K+ loss as in colon
    more common in duodenum than tubular type

    Tubular - more common in jej & ileum, least malig potential

    2. Leiomyoma - Submucosal, smooth convex bulge, folds intact
    ulceration & bleeding common

    3. Lipoma - Submucosal, shape very changeable, pedicle poss

    4. Hamartoma - seen in Puetz-Jeghers syn

    5. Neurofibromatosis - from subserosal nerve or Auerbach's

    6. Cavernous Lymphangioma - irreg dil of lymphatic channels
    rare, asym, changeable like lipoma

    7. Prolapsed Antral Polyp - pain & anemia freq, adenoma #1

    8. Carcinoid or Islet Cell Tumor - same origin & Sx
    Submucosal in ant med position prox to ampulla
    arise from neuroectodermal precusors, argentaffin cells
    Intractable PUD & severe diarrhea, assoc w MEA, freq met
    High endocrine activity - Seritonin, insulin, gastrin
    MALIGNANT CAUSES OF DUO FILLING DEFECTS
    rare, dist to amp, fixed mucosal dest, bleeding, bowel & CBD obs

    1. Adenocarcinoma - #1 malignancy in Sm bowel, still uncommon
    Expansile Type - Villous, can grow into ampulla & Obs
    Infiltrative Type - Circumfrential growth, often narrow
    present w obs, poor prognosis

    Ampullary Adenocarcinoma - Duo, CBD or Panc origin
    Pancreatic Ca has 15X greater occurance
    Present Very sm due to obs, may only be vis w endos US
    Good Prognosis w Whipple resection
    "Silver Stools" - classic clinical sign but rare

    2. Leiomyosarcoma - Lobulated, central ulceration, nec center
    often have lg extramural component

    3. Lymphoma - I' to duo rare, cobblestones

    4. Mets - Gastric, Lymphoma, Panc, GB, colon, kidney, nodes
    Melanoma - bull's eye

    5. Kaposi's Sarcoma - sm plaques or submucosal nodules

    DUODENAL NARROWING AND OBSTRUCTION
    CONGENITAL

    1. Duodenal Atresia - #1, complete obliteration of lumen
    80% dist to ampulla, occurs at 6-11wk gest
    Double Bubble - dil of prox duo develops in interum
    No gas dist to obs, Bilious vomiting at birth
    assoc w down's, malrotation, rib & vert malform, etc

    2. Annular Pancreas - at or prox to ampulla, INCOMPLETE obs
    Double Bubble but dist gas means no atreasia
    May present as adult w inflam of panc etc
    Notch defect in Lat duo
    Pancreas develops from dorsal & double ventral lobes
    Left bud of ventral usually deg, if not this happens
    30% assoc w down's, atresia, Malrotation w bands etc

    3. Doudenal Diaphragm - webs obs in various degree near amp
    2nd or 3rd w prox dil, web may balloon out on exam, "windsock"
    35% assoc w malrotation, 50% have additional webs in GI

    4. Midgut Volvulus - occurs w inc rotation, 20% assoc w above
    Narrow mesenteric attachment to sm bowel
    Rotates around sup mesenteric A
    Lig of Trietz inf & Rt, Spiral loops on R diagnostic

    5. Ladd's Bands - Congenital Peritoneal Bands
    Fibrous bands from malrotated Cecum over ant 2nd
    Intermittent partial obs, standing relaxes bands

    6. Duplication Cyst - rare, may contain mucus or bile
    Intramural or extrinsic on mesenteric side, most asym

    7. Duodenal Diverticulum - sac w halo due to tic wall, rare


    INFLAMMATORY CAUSES OF DOU OBS OR NARROWING
    1. Postbulbar Ulcer - usually shallow & flat in med 2nd
    assoc w incisura of lat wall, resembles annular panc
    Clover-leaf deformity common in duo PUD

    2. Crohn's Dz - long stenosis or spiculated ulcers
    rarely isolated to duo, funnel stom & duo

    3. TB - rare, assoc w other pulm or GI involvement
    diffuse ulceration & luminal narrowing sim to Crohn's
    abcess & fistula common

    4. Sprue - ulcerates w longstanding cases

    5. Pancreatitis - inflam thickens dist duo & mesentaric root
    Cholecystitis can have similar effect
    Psuedocyst in head compresses sweep, no mucosal dest

    6. Strongyloidiasis - can also sim Crohn's


    MALIGNANT CAUSES OF DUO OBS & NARROWING
    1. Pancreatic Ca - 70% in head, narrow 2nd due to invasion
    20% in body, 10% in tail, narrow 3rd & 4th
    Jaundice #1 presenting Sx, often w dull pain & anorexia
    mucosal destruction suggests malig

    2. Adenocarcinoma - 90% of I' duo malig, at or dist to amp
    annular constricting lesion w overhanging edges

    3. Fibro & Leiomyosarcoma - ulcerates, lg extrinsic component

    4. Mets - often difficult to diff I' from II' infil
    Celiac & Periaortic nodes adj to 3rd, can obs & ulcerate


    NONNEOPLASTIC CAUSES OF DUO OBS & NARROWING
    1. Hematoma - 80% children & young adults, see sec on fil def

    2. Aorticoduodenal Fistula - II' to AAA or dacron repair
    pressure nec of 3rd, usually fatal

    3. Radiation - 2nd, ulceration or stricture

    4. Preduodenal Portal Vein - portal ant to duo, incidental
    High assoc w bands, annular panc & malrotation
    obs usually II' to assoc probs rather than ant portal v


    SUPERIOR MESENTERIC ARTERY SYNDROME
    Obs of 3rd (trans) portion w proximal dilation
    mesenteric root w sup mesen vessels & nerves ant
    aorta & lumbar spine post, create sharp linear obs
    Pain, bilious vomitting & relief w flexion common
    obs overcome when pt prone, confirms Dx

    1. Narrowing of the Aorticomesenteric Angle - some congenital
    body casts or fixed hyperextention II' to inj or surg
    anorexia w loss of retroperitoneal fat, or AAA

    2. Reduced Duodenal Peristalsis - scleroderma, SLE, dermatomy
    Aganglionosis - congenital or inflam ie chagas Dz
    Vagotomy or adynamic ileus II' to inflam

    3. Inflammation - PUD, TB, or abcess from panc, biliary etc
    thickens root & duo wall

    4. Lumbar lordosis - duo over convex surface

    5. Chronic Idiopathic Intestinal Psuedo-Obstruction
    may start w duo, progresses to involve entire GI

    4. Pancreatitis - focal dil loop

    5. Acute Intermittent Porphyria - familial metabolic
    Severe colicky pain & obstipation, urine dark w UV expos

    6. Ceroidosis - accum of brown lipofucin in musc propria
    II' to chronic malabsorbtion & vit E depletion

    7. Neotnatal Adynamic Ileus - can primarily effect sm bowel
    II' to any usual cause


    DILATATION WITH NORMAL FOLDS
    N width 3cm, 2-3mm folds at reg intervals, Bx for Dx
    SOS - Scleroderma, Obs, Sprue

    1. Obstruction or Ileus - #1

    2. Scleroderma - Collagen deposits, esp around vasc
    Wide-mouth sacculations, "Hidebound", strictures

    3. Sprue - or any cause of excess fluid, next section
    20% develop lymphoma, 12% get nodes not from lymphoma

    4. Neuromuscular Dysfxn - Vagotomy
    parasym pathways interupted, inc transit & dil
    II' to PUD Tx, look for vagotomy clips
    drugs can simulate vagotomy, see above sec


    EXCESS FLUID IN LUMEN
    can cause dilation, steatorea (bulky fatty stools)
    segnemtation, fragmentation, flocculation

    1. Sprue - Idiopathic, tropical or Celiac Dz in kids
    Villous Atrophy - seen on jejunal Bx
    Dilation - most freq finding
    Moulage - featurless adynamic loops, mid & dist jej
    Barium colum flocculates & segments II' to hypersec
    Reversed jejunoileal fold pattern, ileum inc, jej dec
    Intussuception common, usually transient & nonobs
    Idiopathic & celiac Dz improve w gluten withdrawal
    Tropical improves w folic acid or Antibiotic Tx
    Reactive lymphadenopathy 12%, regresses w gluten free diet
    20% degen to T-cell lymphoma
    Hyposplenism & esoph Ca also seen

    2. Lymphoma - poss complication of sprue, 9mo prognosis
    thickens bowel wall, extraluminal masses

    3. Lactase Deficiency - unable to hydrolyze & absorb lactase
    Blacks, mexicans & Chinese have 75% prevelance
    Cramps & diarrhea 30 min P ingestion
    adding 25-100g of lactase to barium results in dilation
    4. Connective Tissue Dz - Scleroderma #1, other sx seen 1st
    Sm musc atrophy & fibrous dep in mucosal, musc & serosa
    Duo prox to mesenteric A most commonly dil but all poss
    Hidebound - folds packed together despite dil
    Pseudosacculations - Lg broad based pouchs, sim tics
    Dermatomyositis has sim presentation

    5. Blind Loop - bacterial overgrowth causes inflam
    break-down products of bacteria cause osmotic effect

    6. Diabetes w Hypokalemia - II' to neuropathy
    Diarrhea & malabsorbtion assoc

    7. Vascular Insufficiency - dec motility & dec transit = Dil
    intramual bleeding & inc luminal fluid common
    Vasculitis II' to SLE & Amyloid deposition sim

    8. Chronic Idiopathic Intestinal Pseudo-Obstruction
    II' to auerbach's disorder poss, chagas Dz simulates

    9. Long term Crohn's Dz - Dr Doris's 28cm sm bowel


    DILATATION WITH THICKENED MUCOSAL FOLDS
    1. Zollinger-Ellison Syn - nonbeta islet cell tumor, gastrinoma
    parietal cell stim, rugal thickening, PUD
    25% of ulcers occur in dist duo or jej, may be giant
    thickening rarely extends to dist jej
    50% malig, 10% atypical locations, met to liver & nodes

    2. Vascular Insufficiency - venous congestion, emboli esp

    3. Inflammatory - Crohn's, TB, radiation
    infiltration of mesentary w lymph or venous blockage
    Mets work in a similar fashion
    Infectious enteritis - esp in immune comp pt
    Salmonella, Strongyloides, Candida, CMV, crypto, myco

    4. Infiltrative processes - occurs in late stages, rare
    Lymphoma primarily submucosal
    amyloid -depostited around sm blood vessels
    abetalipoproteinemia - fat droplets in mucosal cells

    5. Hypoalbuminemia - alb <2.7 g/dl

    6. Lymphoma - often causes aneurysmal dilation & fold thicken


     

     

     

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